|
Cannula O2 Hi-Flo Adult
|
Facility
|
IP
|
$4.55
|
|
| Hospital Charge Code |
3251574
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.09 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.09
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.32
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Cannula O2 Tubing Holder Fixation Device All Ages Tender Grip
|
Facility
|
OP
|
$4.55
|
|
| Hospital Charge Code |
3255750
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.82 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$4.09
|
| Rate for Payer: Humana Medicare Advantage |
$1.91
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.82
|
| Rate for Payer: WPPA Medicare Advantage |
$2.73
|
|
|
Cannula O2 Tubing Holder Fixation Device All Ages Tender Grip
|
Facility
|
IP
|
$4.55
|
|
| Hospital Charge Code |
3255750
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.09 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.09
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.32
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Cannula Pediatric 7ft - with Elastic Head Strap
|
Facility
|
OP
|
$6.84
|
|
| Hospital Charge Code |
3255317
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.74 |
| Max. Negotiated Rate |
$6.50 |
| Rate for Payer: Aetna Commercial |
$6.16
|
| Rate for Payer: Humana Medicare Advantage |
$2.87
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.74
|
| Rate for Payer: WPPA Medicare Advantage |
$4.10
|
|
|
Cannula Pediatric 7ft - with Elastic Head Strap
|
Facility
|
IP
|
$6.84
|
|
| Hospital Charge Code |
3255317
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.16
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.50
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Cannula Small Adult/Pediatric Vapotherm
|
Facility
|
IP
|
$68.00
|
|
| Hospital Charge Code |
3250562
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$61.20 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$61.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$64.60
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Cannula Small Adult/Pediatric Vapotherm
|
Facility
|
OP
|
$68.00
|
|
| Hospital Charge Code |
3250562
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$27.20 |
| Max. Negotiated Rate |
$64.60 |
| Rate for Payer: Aetna Commercial |
$61.20
|
| Rate for Payer: Humana Medicare Advantage |
$28.56
|
| Rate for Payer: UnitedHealthcare Commercial |
$64.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$27.20
|
| Rate for Payer: WPPA Medicare Advantage |
$40.80
|
|
|
Cannulated Drill Bit 3.6MM
|
Facility
|
OP
|
$812.50
|
|
| Hospital Charge Code |
3258555
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$325.00 |
| Max. Negotiated Rate |
$771.88 |
| Rate for Payer: Aetna Commercial |
$731.25
|
| Rate for Payer: Humana Medicare Advantage |
$341.25
|
| Rate for Payer: UnitedHealthcare Commercial |
$771.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$325.00
|
| Rate for Payer: WPPA Medicare Advantage |
$487.50
|
|
|
Cannulated Drill Bit 3.6MM
|
Facility
|
IP
|
$812.50
|
|
| Hospital Charge Code |
3258555
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$731.25 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$731.25
|
| Rate for Payer: UnitedHealthcare Commercial |
$771.88
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Cannula Ventilator HFT Large Headgear for V60 Bipap
|
Facility
|
OP
|
$95.00
|
|
| Hospital Charge Code |
3250566
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$38.00 |
| Max. Negotiated Rate |
$90.25 |
| Rate for Payer: Aetna Commercial |
$85.50
|
| Rate for Payer: Humana Medicare Advantage |
$39.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$90.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$38.00
|
| Rate for Payer: WPPA Medicare Advantage |
$57.00
|
|
|
Cannula Ventilator HFT Large Headgear for V60 Bipap
|
Facility
|
IP
|
$95.00
|
|
| Hospital Charge Code |
3250566
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$85.50 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$85.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$90.25
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Cannula Ventilator HFT Medium - Headgear for V60 Bipap
|
Facility
|
IP
|
$95.00
|
|
| Hospital Charge Code |
3250565
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$85.50 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$85.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$90.25
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Cannula Ventilator HFT Medium - Headgear for V60 Bipap
|
Facility
|
OP
|
$95.00
|
|
| Hospital Charge Code |
3250565
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$38.00 |
| Max. Negotiated Rate |
$90.25 |
| Rate for Payer: Aetna Commercial |
$85.50
|
| Rate for Payer: Humana Medicare Advantage |
$39.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$90.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$38.00
|
| Rate for Payer: WPPA Medicare Advantage |
$57.00
|
|
|
Capcephalexin 500 mg Cap [HMC]
|
Facility
|
OP
|
$9.06
|
|
|
Service Code
|
NDC 60687016301
|
| Hospital Charge Code |
3804800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$8.61 |
| Rate for Payer: Aetna Commercial |
$8.15
|
| Rate for Payer: Humana Medicare Advantage |
$3.81
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.62
|
| Rate for Payer: WPPA Medicare Advantage |
$5.44
|
|
|
Capcephalexin 500 mg Cap [HMC]
|
Facility
|
IP
|
$9.06
|
|
|
Service Code
|
NDC 60687016301
|
| Hospital Charge Code |
3804800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.15 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$8.15
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.61
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
capsaicin Top 0.025% Crm [HMC]
|
Facility
|
IP
|
$37.41
|
|
|
Service Code
|
NDC 00536252525
|
| Hospital Charge Code |
3800620
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.67 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$33.67
|
| Rate for Payer: UnitedHealthcare Commercial |
$35.54
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
capsaicin Top 0.025% Crm [HMC]
|
Facility
|
OP
|
$37.41
|
|
|
Service Code
|
NDC 00536252525
|
| Hospital Charge Code |
3800620
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.96 |
| Max. Negotiated Rate |
$35.54 |
| Rate for Payer: Aetna Commercial |
$33.67
|
| Rate for Payer: Humana Medicare Advantage |
$15.71
|
| Rate for Payer: UnitedHealthcare Commercial |
$35.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.96
|
| Rate for Payer: WPPA Medicare Advantage |
$22.45
|
|
|
capsaicin topical 8% Kit [HMC]
|
Facility
|
OP
|
$4,313.79
|
|
|
Service Code
|
HCPCS J7336
|
| Hospital Charge Code |
3801960
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.42 |
| Max. Negotiated Rate |
$4,098.10 |
| Rate for Payer: Aetna Commercial |
$3,882.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$4.22
|
| Rate for Payer: Humana Medicare Advantage |
$1,811.79
|
| Rate for Payer: UnitedHealthcare Commercial |
$4,098.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.42
|
| Rate for Payer: WPPA Medicare Advantage |
$2,588.27
|
|
|
capsaicin topical 8% Kit [HMC]
|
Facility
|
IP
|
$4,313.79
|
|
|
Service Code
|
HCPCS J7336
|
| Hospital Charge Code |
3801960
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$4,098.10 |
| Rate for Payer: Aetna Commercial |
$3,882.41
|
| Rate for Payer: UnitedHealthcare Commercial |
$4,098.10
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
carBAMazepine 200 mg Tab [HMC]
|
Facility
|
OP
|
$7.04
|
|
|
Service Code
|
NDC 68084044401
|
| Hospital Charge Code |
3808918
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$6.69 |
| Rate for Payer: Aetna Commercial |
$6.34
|
| Rate for Payer: Humana Medicare Advantage |
$2.96
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.82
|
| Rate for Payer: WPPA Medicare Advantage |
$4.22
|
|
|
carBAMazepine 200 mg Tab [HMC]
|
Facility
|
IP
|
$7.04
|
|
|
Service Code
|
NDC 68084044401
|
| Hospital Charge Code |
3808918
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.34 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.34
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.69
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
carBAMazepine 200 mg Tab [HMC]
|
Facility
|
OP
|
$8.36
|
|
|
Service Code
|
NDC 00904617261
|
| Hospital Charge Code |
3808918
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.34 |
| Max. Negotiated Rate |
$7.94 |
| Rate for Payer: Aetna Commercial |
$7.52
|
| Rate for Payer: Humana Medicare Advantage |
$3.51
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.94
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.34
|
| Rate for Payer: WPPA Medicare Advantage |
$5.02
|
|
|
carBAMazepine 200 mg Tab [HMC]
|
Facility
|
IP
|
$8.36
|
|
|
Service Code
|
NDC 00904617261
|
| Hospital Charge Code |
3808918
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.52 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$7.52
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.94
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
carBAMazepine 200 mg Tab [HMC]
|
Facility
|
OP
|
$9.80
|
|
|
Service Code
|
NDC 51079038520
|
| Hospital Charge Code |
3808918
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.92 |
| Max. Negotiated Rate |
$9.31 |
| Rate for Payer: Aetna Commercial |
$8.82
|
| Rate for Payer: Humana Medicare Advantage |
$4.12
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.31
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.92
|
| Rate for Payer: WPPA Medicare Advantage |
$5.88
|
|
|
carBAMazepine 200 mg Tab [HMC]
|
Facility
|
IP
|
$9.80
|
|
|
Service Code
|
NDC 51079038520
|
| Hospital Charge Code |
3808918
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.82 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$8.82
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.31
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
